On the 'ring of fire' theme, are there any doctors/midwives/ medical people out there who can answer my question?

[janey68]

I've had two children, natural births, had a few whiffs of g and a around transition during labour, but it was then whisked off me for the pushing stage.

Now, let me be clear that on balance I am very very pleased that I had low tech births in a midwife unit with no interventions and over medicalisation.

BUT I have to be honest, I found the second stage of labour, actually pushing the baby out, excruciating. I think what shocked me was that I felt I coped relatively well with first stage; yes it was long and painful, especially the first dc, but I feel I "rode" through the contractions pretty well using relaxation and breathing. However, second stage was sooo painful I wanted to die (I tore first time too.) For this reason alone, when I fell pg with dc2 I almost considered going to hospital for the delivery so I had more access to pain relief. What swung it in the end and made me decide to stick with the MLU again was that from what I could gather, the only option would be going the whole epidural route so id be numbed up. I really didn't want this, because it seemed a bit like a sledgehammer to crack a nut: I had already coped with a 16 hour first stage with dc1 and I didn't want the increased risk of interventions, being strapped to a monitor etc with dc2, just to avoid the pain of pushing the baby out

Sorry, this is long winded but what I'm leading up to, is why aren't there more methods of pain relief or support for women like me (I'm sure I'm not the only one) who don't want to be numbed up in hospital with the heavy duty epidural route, but also don't want to feel 100% the pain of the baby actually coming out? I know local anaesthetics are used for forceps , which presumably doesn't completely block the pain like an epidural but must take the worst edge of it off. Why can't an injection be given by the midwife even if forceps aren't used? Or some sort of numbing cream?

My child bearing days are past, and in one sense I am glad like I said that my births were natural because I did find that to cope with that level of intensity and pain was empowering, so I don't regret it, and the MLU was a much calmer and positive place to give birth than a hospital. But I do ponder this sometimes: whether it needed to be so excruciating. Is it really a case of having the complete medicalised route of epidural, or nothing (I say nothing because most mums I know who had just g and a like me had it taken off for the pushing stage, and unlike other pain relief, the effect is lost immediately, as soon as you breathe in that final gasp of it).
I'd be so interested to hear what any medical people have to say on this

TIA

Sorry I can't answer your question but I thought I'd add that with my 3 deliveries I used the gas and air between pushes so I was anaesthetised for the actual push iykwim.

That's interesting cafebistro; clearly it varies from place to place . My midwife (who was lovely btw) just removed the g and a because it made me woozy and she felt wasnt helping me push effectively. Woozy is great for first stage when you're trying to ride through the pain, but second stage is bloody hard physical pushing.

You can have mobile epi now (not sure how long they have been available, or wide spread they are avaialble now), but it means you can have an active ish labour with some of the pain relief of an epi.

I'm preg for the first time so no idea if/how this really works, just know it routine at my hospital (if you want an epi of course).
Also my sis used g&a during pushing so that must varry place to place or preg to preg.

Thanks. Yes a mobile epidural was available at the hospital I could have gone to, but it would still have meant going to the huge regional hospital and having an anaesthetist in attendance which in my view makes the whole affair medicalised and more likely to result in intervention, though of course a mobile epidural would be the better of the two options rather than an old style one.

What I would really have liked is something accessible in a MLU or home situation, where you don't need doctors and anaesthetists, just a midwife. IMO normal pregnancy and birth doesn't necessitate doctors; the midwife is the specialist in normal situations (I appreciate that this is my view and that not all women agree and indeed many actively choose hospital and epidural)

Another one who had g&a for the pushing phase! I don't remember it impacting on my ability to push at all - just gave me something to do between pushes. Not sure it helped much with the pain either mind...

I had g&a for my labour. It did bugger all for the pain, I was just using the mouth piece for biting on to be honest.

I found labour excruciatingly painful. I just wanted it over.

I'm not sure why you couldn't have had something like pethedine in the MLU? There are halfway houses between g and a and epidurals

I had 2 mobile epidurals and in both cases could feel enough to tell mw I needed to push. Requested them because I didn't want the ring of fire pain or to feel myself tearing and could have managed (only just!) the contractions with g&a. COI I'm an anaesthetist so medicalised birth didn't bother me at all but accept am very much in the minority!

In answer to op's question unfortunately the systemic drugs cross the placenta and will have an effect on the baby that close to delivery and there aren't any very effective and reliable local anaesthetic techniques that could be used. There is a newish drug some units use called remifentanil which has a similar profile as gas and air in terms of timing its onset with contractions and offset. The person who can find the wonder-drug/technique for use during transition will be a very rich one!

Thanks picklebean, that's interesting.

Comtesse- yes, I could have had pethidine administered by a midwife. But I wasn't keen for the reasons picklebean describes: this sort of drug crosses the placenta, and therefore no one will be keen to administer it close to the delivery. I think you've highlighted that actually IMO there isnt really a half way house between g and a, and the whole medicalised epidural route. G and a is great for making you feel a bit spaced out, but doesn't stop the pain. Epidural great for blocking pain but means hospital and anaesthetist (plus possible cascade of intervention)

I agree that anyone who develops the wonder drug which can be administered just for that phase when the baby is emerging, not to Block the pain of contractions but simply to block the ring of fire and pain from tearing would be a very rich person.

I had G&A during pushing, and also had pethidine 20 minutes before delivery. I was also in a MLU, (nearest hospital 40 miles away, so no epidural even if I wanted it!)

I didn't feel the ring of fire, and I suppose that was the drugs, which I was VERY thankful for. Labour was extremely painful for me, and to suddenly have that pain taken away with the ability to still feel the contractions was just amazing. I had no break between contractions for quite a while towards the end and the pethidine gave me the chance to breath and stop being so hysterical!

I would maybe consider having pethidine again, even if it did make both me and baby very very sleepy and also made me vomit afterwards. But I also had a back to back labour. Because I've had it once, I'd be more aware of the effect on the baby (like it's harder to BF a drugged up baby).

I had a pudendal nerve block just as an episiotomy was done for forceps delivery - I could certainly feel the awful deep pain of the forceps but didn't feel the cut or tear at the time (I tore too). I don't know if a pudendal nerve block would take away the ring of fire pain? I assume it would need to be done by a clinician anyway, so maybe not in an MLU? But it's a good question; why don't they do a pudendal nerve block routinely? (BTW I did feel the injection for it and that did hurt.)

Georgettemagritte: that's interesting. I know from ante natal care at my MLU that on occasions the midwife would call in a doctor from the local practice if it looked like forceps would be needed. Apparently this happened if the birth was close enough that transfer to hospital wasnt appropriate, but it looked like the baby needed some help out. We were told that the midwifes couldn't use forceps- this needed to be one of the GPs who had had specialist training, but the midwife could administer the local anaesthetic injection. I imagine there are also situations where a midwife needs to administer the injection and do an episiotomy without forceps being on the agenda too

So yes, your question about whether a pudendal nerve block could be administered routinely even if the mother doesn't need to be cut, is a good one. I'm sure an injection into that area is painful, but having experienced agonising pain with crowning and tearing (2nd degree tear into skin and muscle with no pain relief) I would have been seriously tempted to consider this with dc2

Hopefully some medical person will be back to tell us more

Out of interest, the only women I know who've had forceps, had an epidural. Was it really awful even with the pudendal block? Sounds from what you say as though the injection numbs only the vaginal opening rather than the passage?

I was terrified of crowning with DS2 (DS1 was forceps with spinal so didn't feel a thing) so MW injected perineum with lidocaine (sp?) just before he crowned. She said it wouldn't take away the sensation completely but would take the edge off. Was such a blur I couldn't say if it helped or not though. She did say that a lot of MWs don't like to do this but I'm not sure why.

Not a drug, but I've read that water is the second most effective form of pain relief, after epidural. I've used it twice and while it certainly didn't take all the pain away, it was better than the g&a/pethidine I was given first time around.

RegLlama- that's exactly the type of pain relief which could have made a big difference to me. It seems its something which is perhaps popular in certain hospitals and with certain midwives, but not universally used

I feel quite strongly about this, because I think there is a wide gulf between epidural, which is essentially heavy duty pain relief, requiring a hospital, an anaesthist, close monitoring, is expensive etc, and other forms of pain relief.

I have talked to other women who feel the same. Their pregnancy isn't high risk, they don't have a medical need to be in hospital, they don't want to be number up so they can't feel the birth, but they don't want to have to feel 100 % of the pain, particularly in the event of tearing. If there are other options out there, relatively cheap ( and let's face it, anything which can be administered by a midwife at home or in a MLU has got to be loads more cost effective than bringing someone into hospital and using anaesthetists) then surely they ought to be more widely available?

I totally agree with you OP. I do wonder why the pudendal block is not used more often. Of course it is administered by a doctor so would still not be available in an MLU, but I think it would be a good option for women on a labour ward who don't necessarily want an epidural but want analgesia for the second stage.

I have also seen midwives occasionally inject lidocaine at the perineum, even without an epis, to take away the worst of the stinging.

The other good thing about a pudendal block is that it is still effective for suturing, which can be very sore for some women even with lidocaine.

Bue- I'm sure the midwife can administer the block though. I had stitches, and the midwife definitely injected some type of local anaesthetic first (though I did need a few whiffs of gas and air during stitching too). That's a BIG advantage of the pudendal nerve block IMO- that it can be administered by a midwife, in a MLU or at home I assume (some women need stitching at home)

Whereas epidural requires an anaesthetist, it requires being in hospital, it necessitates constant monitoring... To go back to my OP, it can seem a bit like a sledgehammer to crack a nut, for women who don't want to be completely medicalised and numbed up, but just don't actually want to feel themselves stretching and tearing. And an expensive sledgehammer at that. We're often hearing about the push to reduce expensive hospital procedures. I'm not saying cost should be uppermost in people's minds because there will always be women who choose hospital and epidural. But the more I think about it, the more I cannot understand why these practices aren't more widely used by midwives.

In the MLU I went to, the midwives were desperate to get more women to deliver there. They had about 80 births per year, but most of their business was with mums transferring back for the far superior post natal care, having delivered in hospital. Midwives are the experts in birth, and I could see it was a bit frustrating for them to be so damn good at their job, but to feel that most of the women who passed through didn't actually make use of the MLU to deliver. It may well encourage more women to use MLUs if they know that there's more standardisation about how things like pudendal blocks are used

It would be good to hear perspectives from any midwives .. I know there are a few on MN

janey, what you had was lidocaine in the perineum, which the midwife always injects prior to episiotomy or suturing. A pudendal block is only done by an obstetrician (or I suppose an anesthetist, although I've only seen it done by an OB prior to forceps) as it is a more complicated procedure, where lidocaine is injected into the pudendal canal. It gives a more total block than just the lidocaine in the perineum (although I think that in itself is a good option for some women).

Very jealous of those who had g&a during pushing, the midwife ripped it off me at the start of 70-odd minutes of pushing. DH thinks it was because it made me sick once, but honestly I couldn't care less if I'd been sick all the way through.

DS's head was 98th centile and I was labouring on my back due to constant monitoring as he was having decels. I still resent being stripped of the G&A.

Also - I'm not sure but I am just thinking this through - from what I have seen they are rather a faff to get sited properly, so perhaps they simply aren't worth the trouble. I plan to look into this a bit more now! (Am st/mw)

This is really interesting bue

What is it the midwife injects if she's doing an episiotomy?

Also, I thought there were some tasks now which midwives are trained to do, which previously only doctors could?

Lidocaine is used in both cases, it just goes in a different place :)

Janey68 - yes it numbed just the perineum and opening, not anything else, and was administered by the OB who was doing the forceps (I didn't have a spinal or epidural as there wasn't time - sudden and serious foetal distress and no time for anaesthetic or a section - I think a spinal block takes at least 15-20 mins to work...) Thankfully, baby all OK because was got out very quickly, but my goodness the instrumental delivery was agonising!

Having just looked it up it looks like the pudendal block is a bit tricky to site and needs a good deal of experience to administer. Still, it would presumably make a big difference to the experience of crowning and the fear of tearing.

So why not have lidocaine routinely injected during crowning?

This thread is a bit depressing, if there is something that might help hundreds of women that is not being done.